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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005701
Report Date: 08/14/2023
Date Signed: 08/14/2023 01:21:24 PM

Document Has Been Signed on 08/14/2023 01:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTERFACILITY NUMBER:
306005701
ADMINISTRATOR:MICHAEL VILLARREALFACILITY TYPE:
772
ADDRESS:25481 GLORIOSA DRIVETELEPHONE:
(949) 533-3046
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
08/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Andrew Crawford- Program DirectorTIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho made a subsequent visit for the purpose to issue a citation after observing a deficiency while conducting the 10-day complaint investigation into complaint control number: 22-AS-20230808153628.

At 9:28 am, LPA along with Staff #1 (S1) observed a cockroach in the Medication Room, therefore the preponderance of evidence standard has been met. Program Director Andrew Crawford was informed of the observance of the cockroach upon arrival.

Based on LPA's observation along with S1, a deficiency is being cited as per Title 22, Division 6, Chapter 1 of the California Code of Regulations. See the attached LIC809-D.

An exit interview was conducted with Program Director Andrew Crawford, and a copy of this report including the LIC809-D were provided to Administrator Michael Villarreal via email during today's visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/14/2023 01:21 PM - It Cannot Be Edited


Created By: Jessica Cho On 08/14/2023 at 12:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER
FACILITY NUMBER: 306005701

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/28/2023
Section Cited
CCR
80087(a)(1)

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80087 Building and Grounds (a) The facility shall be clean, safe, sanitary...for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.
This requirement was not met as evidenced by:
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Licensee to provide proof of treatment completed by a certified pest control company to LPA via email by POC due date.
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Based on LPA's observations along with S1, a cockroach was observed in the Medication Room which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


LIC809 (FAS) - (06/04)
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